Documentation Craven Ch. 15

1. DocumentationCraven Ch. 15 9/24/2014 NRS 320 2012 1

2. Why communication is important NRS 320 2012

3. Patient Medical Record • Purposes of the medical record • Clear, accurate, and up-to-date patient documentation of • Patient’s progress • Care provided • Legal document • Communication to HCT • Assessment information/changes • Care planning [ADPIE] NRS 320 2012

4. Patient Medical Record (Cont’d) Purposes of the medical record Quality assurance Reimbursement Research Education NRS 320 2012

5. Principles of documentation • Confidential • Accurate • Complete • Concise • Objective • Organized • Timely • Legible NRS 320 2012

6. Documentation • Documentation style varies by facility • Content should be similar • Factual, concise LEGAL RECORD • Arranged by Nursing Diagnosis or Focus • Time of charting, assessment, what was done [when/why], effect/response • Sign name, title • Error? One line through and initial NRS 320 2012

7. Nursing Entries in the Patient Record Patient care summary or Kardex Admission entries Flow sheets Charting by exception [CBE] Nursing progressnotes Narrative notes FOCUS DART notes Plan of care NRS 320 2012

8. Nursing Entries in the Patient Record (Cont’d) Written handoff summary When care or patient is transferred Nursing discharge summary Usually standardized Medication administration record [MAR/eMAR] Documentation of care in non–acute care settings Incident report Not part of patient chart NRS 320 2012

9. DAR(T) Charting • D = Data • “pt. c/o pain 6/10 in L hip at 1245” • A = Action • “ Fentanyl 50 mcg IVP given @ 1300” • R = Response • “Pt. rated pain at 2/10 within 10 min” • T = Teaching • “Reminded pt. to request analgesics when pain > 3/10; reviewed side effects/fall risk ” NRS 320 2012

10. DART charting • (ND: acute pain r/t tissue trauma) • 1330: D-pt. c/o pain 6/10 in L hip. A- Fentanyl 50 mcg IVP given @ 1300. R- Pt. rated pain at 2/10 within 10 min. T - Reminded pt. to request analgesics when pain > 3/10; reviewed side effects/fall risk. _______________________CCollingsRN NRS 320 2012

11. DART Example 2 • 10/5/2012 1145 • Nursing Diagnosis: Nausea R/T anesthetic • D: Pt. states, “I feel nauseated.” vomited 100 mL of yellow/green fluid at 1055. • A: Pt. given Compazine 10 mg IV at 1100. Will monitor pt.'s response to med. • R: Pt. voiced relief of nausea at 1130 and has had no further episodes of vomiting. • T: Call light & emesis basin in reach; sips of ginger ale encouraged. CCollingsRN NRS 320 2012

12. Example 3 • Nursing Diagnosis: Risk for infection related to surgical incision • 10/5/2012 1400 • D: Incision site in front of left ear extending down and around the ear and into the neck. Incision is approximately 6” in length, edges well approximated with sutures intact. No dressing present. Incision without redness, swelling or drainage however, bruising noted below the left ear. JP drain intact in left neck with approx. 20 mL of bloody drainage. • A: Will continue to monitor and assess incision and drain site for any signs of redness, swelling or drainage. Will also monitor temp. every 4 hours, change dressing PRN • R: Currently no evidence of infection noted. Pt. afebrile. • T: Taught pt. and family signs and symptoms of infection to watch for upon discharge. Pt. and family voiced understanding of information provided. CCollingsRN NRS 320 2012

13. Narrative Charting • Usually in long-term care • Can use DART format as in example 1 • ND/ focus in margin • Sometimes use DRG as focus • Combines info for shift into 1 paragraph • Concise but complete NRS 320 2012

14. Computer Charting • Usually in acute settings; becoming near universal • Chart by exception • Use ‘Nurses Notes’, Progress Notes or other area for DART charting NRS 320 2012

15. Legal Implications • If it isn’t documented, it isn’t done • Exception is CBE • What you document is the legal record of what happened • Will you remember 5 or 10 years from now? • Balance between complete and concise • What, When, Why, Who • Never document until done NRS 320 2012

16. Documenting in the MAR • Draw meds for ONE pt at a time • Mark med cup with pt initials • As you dispense each pill, make a dot where you will sign • Notice what pills look like [in case of drop] • When taken, go back and initial • Sign at bottom/back of page NRS 320 2012

17. eMAR [electronic MAR] • Document administration of medications • As soon as administered • Generated by pharmacy • Routine administration times indicated • PRN meds: • Time, reason, effectiveness • Drug not given? • Note reason NRS 320 2012

18. What NOT to chart • ‘Pt. tolerated well’ • No complaints [use ‘denies pain’] • ‘Difficult pt.’ [describe behavior instead] • Terms you don’t understand – • Describe sounds, drainage if not sure of correct term • Error-prone Abbreviations • Table15-1, pg. 245-6 NRS 320 2012

19. Documentation Discussion Mrs. Smith had a terrible night. She was bloated and very nauseated. BS present X 4 quadrants. C/O doctor never coming to see her and not being interested in how she felt when he does. VS: B/P 176/74, P 92, R18, O2 Sat 95% C/O incisional pain; MS given. She was also upset about her family. SDoofus,RN NRS 320 2012

20. Documentation Discussion Identify missing information you need to assume care for Ms. Smith What legal and ethical problems does this documentation present? What positive qualities are included in this charting? Find 3 Construct a correctly written DART chart entry for this info; use hypothetical data as needed. NRS 320 2012